Provider Demographics
NPI:1912922634
Name:DE SILVA, CONSTANCE PRIMROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:PRIMROSE
Last Name:DE SILVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 W LA VETA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3918
Mailing Address - Country:US
Mailing Address - Phone:715-532-6811
Mailing Address - Fax:714-532-5487
Practice Address - Street 1:810 W LA VETA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3918
Practice Address - Country:US
Practice Address - Phone:715-532-6811
Practice Address - Fax:714-532-5487
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 334502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA 33450MOtherPPIN
CAW13067Medicare PIN
CAWA 33450MOtherPPIN